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DOI: 10.1111/cdoe.12392
ORIGINAL ARTICLE
1
Centre for Oral Health and Performance,
University College London, Eastman Dental Abstract
Institute, London, UK Objectives: To measure dental caries, erosive tooth wear (ETW), periodontal health,
2
UK IOC Research Centre for Prevention of
self-reported oral health problems and performance impacts in a representative sam-
Injury and Protection of Athlete Health,
London, UK ple of UK elite athletes from different sports using standardized conditions clearly
defined clinical indices and a measure of impact on performance with evidence of
Correspondence
Ian Needleman, Centre for Oral Health and validity in sport.
Performance, Department of Periodontology,
Methods: Cross-sectional study, with single, calibrated examiner, conducted in the
University College London, Eastman Dental
Institute, London, UK. local facilities of elite and professional UK athletes (UCL ethics number 6388/001).
Email: i.needleman@ucl.ac.uk
Main oral measures: dental caries (ICDAS), erosive tooth wear (BEWE), periodontal
Funding information health (BPE) and athlete-reported performance impacts.
University College London IMPACT award,
Results: We recruited 352 athletes from eleven sports. The mean age was 25 years
Grant/Award Number: 157871;
GlaxoSmithKline, Grant/Award Number: (range 18-39), and 67.0% were male. We found caries (ICDAS code ≥3) in 49.1% of
157871
athletes, ETW (BEWE score of ≥7) in 41.4%, gingival bleeding on probing/presence
of calculus (BPE score 1 or 2) in 77.0% and pocket probing depths of at least 4 mm
(BPE score 3 or 4) in a further 21.6%. One in five athletes reported previous wis-
dom teeth problems. The odds of having caries were 2.4 times greater in team sport
than endurance sport (95% CI 1.3-3.2). The odds of having erosion were 2.0 times
greater in team sport than endurance sport (95% CI 1.3-3.1). Overall, 32.0% athletes
reported an oral health-related impact on sport performance: oral pain (29.9%), diffi-
culty participating in normal training and competition (9.0%), performance affected
(5.8%) and reduction in training volume (3.8%). Other impacts were difficulty with
eating (34.6%), relaxing (15.1%) and smiling (17.2%). Several oral health problems
were associated with performance impacts.
Conclusions: This is the first large representative sample study of oral health in ath-
letes from different sports at elite level. Although experience of oral disease differs
by sport, the prevalence, in UK elite and professional athletes, is substantial, with
common self-reported performance impacts. Regular screening and use of effective
oral health promotion strategies may minimize performance impacts from poor oral
health.
KEYWORDS
caries detection/diagnosis/prevention, epidemiology, outcomes research, periodontal disease(s)/
periodontitis, sports dentistry, tooth wear
Community Dent Oral Epidemiol. 2018;1–6. wileyonlinelibrary.com/journal/cdoe © 2018 John Wiley & Sons A/S. | 1
Published by John Wiley & Sons Ltd
2 | GALLAGHER ET AL.
study with questionnaire data available for up to 344 (97.7%, 95% Mixed
Endurance
CI 95.5-98.9). The main reason for nonattendance at the screening Strength and power
appointment was training or competing elsewhere. Eight question-
Rugby
naires were not returned due to time constraints. We achieved our Football
target of at least 75% completeness in all sports except athletics Sailing
Gymnascs
(26.3%, 95% CI 17.8-36.9). Overall, we screened 79.4% (95% CI Hockey
Rowing
75.4-83.0) of eligible athletes (Figure 1). Athlecs
The median age of the participants was 25 years (range 18-39), Swimming
Cycling
and 67.0% were male (Table S1). Two hundred and seventy-five
0 10 20 30 40 50
(80.4%, 95% CI 75.4-83.9) athletes recorded ethnicity as white Bri-
% of total sample
tish, and 162 (47.4%, 95% CI 41.9-52.4) said they had or were
studying for a University degree. There were 50 (14.2%, 95% CI F I G U R E 2 Percentage contribution of each sport and sport
10.9-18.3) athletes in the strength and power category (athletics, category to the total sample
gymnastics, sprint cycling and sprint swimming), 143 (40.6%, 95% CI severity, 41 (11.7%; 95% CI 8.7-15.5) athletes scored between 9 and
35.6-45.8) in the endurance category (swimming, cycling, rowing,) 13. ETW was most prevalent in football (73.1%; 95% CI 53.7-86.5)
and 159 (45.2%, 95% CI 40.0-50.4) in the mixed category (football, and least prevalent in sailing (26.7%; 95% CI 10.5-52.4) and rowing
rugby, hockey, sailing). The demographic make-up of the endurance (26.7%; 95% CI 17.0-39.1). ETW differed between mixed (51.6%;
and mixed sports categories was similar, but those in the strength 95% CI 43.9-59.2) and endurance (35%; 95% CI 27.6-43.1) sports
and power category were younger and composed more females and categories (OR 2.0; 95% CI 1.3-3.1, P = .015).
athletes from ethnic groups other than white British. We found excellent periodontal health (BPE code 0 as worst
The median number of sound and unrestored teeth per athlete score) in 4 (1.1%; 95% CI 0.3-3.0) athletes. Gingival bleeding on
was 27 (range 12-32), and 173 (49.1%; 95% CI 44.0-56.6) had an probing/calculus or other plaque retentive factors present (BPE
established carious lesion (ICDAS code ≥3) in at least one tooth codes 1 or 2) as the worst finding was present in 77.3% (95% CI
(Tables S2,S3). Of those with caries (DT ≥ 1), the median number of 72.6-81.3) of athletes and a pocket probing depth of ≥4 mm (BPE
teeth affected was 2 (range 1-13). For those with one or more code 3 or 4) in a further 21.6% (95% CI 17.6-26.2). In terms of
restorations (71.6%; 95% CI 66.7-76.1), the median number of teeth extent, 87.5% (95% CI 83.3-90.3) of athletes had a BPE score of at
affected was 4 (range 1-19). Caries was not associated with age, least 1 in three or more sextants (Tables S5,S6).
gender, ethnicity or education; however, the percentage with DT ≥ 1 We recorded infections around wisdom teeth at the time of clini-
was highest in rugby (61.1%; 95% CI 49.5-71.5) and football (61.5%; cal examination for 4 (1.1%; 95% CI 0.3-3.0) of athletes, and 12 (3.4%;
95% CI 42.5-7.6) and lowest in rowing (33.3%; 22.7-46.0). The per- 95% CI 1.9-5.9) had at least one PUFA finding. The proportions of ath-
centage with DT ≥ 1 in the mixed sport category (56%; (95% CI letes reporting oral health problems were 7.7% (95% CI 5.3-11.0) cur-
48.2-63.5) was higher than that in endurance (38.5%; 95% CI 31.0- rent pain or problem related to teeth, 26.7% (95% CI 22.3-31.6)
46.4) with an odds ratio of 2.03 (95% CI 1.3-3.2). sensitivity to hot or cold, 23.3% (95% CI 19.1-28.0) swelling/infection
Overall, 41.4% (95% CI 37.0-47.3) of athletes had ETW with a around wisdom teeth in previous 12 months, 12.8% (95% CI 9.7-16.7
difference between the genders (Table S4); 48.7% of men and sport-related dental trauma in previous 12 months and 39.0% (95% CI
28.4% of women had a BEWE score of ≥7 (P < .001). In terms of 34.0-44.1) bleeding when cleaning teeth at least occasionally.
Total 79.4
Swimming (46) 92
0 10 20 30 40 50 60 70 80 90 100
% completeness
FIGURE 1 Sports, numbers of athletes recruited to the study and percentage completeness of each sample group
4 | GALLAGHER ET AL.
Nine of ten athletes (90.1%; 95% CI 86.5-92.9) assessed their gen- The most commonly reported impacts were oral pain (29.9%)
eral health as very good or good, and seven of ten (69.2%; 95% CI and difficulties with eating (34.6%). Other impacts were difficulty
64.1-73.8) assessed their oral health at this level (Tables S7,S8). Overall, relaxing (15.1%), smiling (17.2%) and participation in normal training
169 (49.1%; 95% CI 43.9-54.4) athletes reported a nonzero score for and competition (9.0%). Furthermore, 5.8% felt their performance
one or more psychosocial impacts within the previous 12 months was affected and 3.8% reported a reduction in training volume.
(Tables S9,S9a): difficulty eating or drinking; 119 (34.6%; 95% CI 29.8- This study has several strengths. This is the most methodologi-
39.8), difficulty relaxing (including sleeping); 52 (15.1%; 95% CI 11.7- cally robust study to evaluate oral health and associated self-
19.3), difficulty smiling, laughing or showing teeth without embarrass- reported performance impacts in elite athletes across different sports
ment; 59 (17.2%; 95% CI 13.5-21.5). The odds of an oral impact on and is one of the largest studies of oral health in sport with 352 ath-
daily performance were 2.7 (95% CI 1.2-6.0) times greater in cycling letes recruited. We achieved a 75%-100% sample in each team/
than rowing (P = .013). Overall, 110 (32.0%; 95% CI 27.3-37.1) ath- sport with track and field the only exception at 26%. All examina-
letes reported a nonzero score for one or more sport performance tions were conducted by a single experienced dentist using clearly
impacts within the previous 12 months (Tables S10,S10a): difficulty in defined clinical and valid self-reported outcome measures; the inclu-
participating in normal training and competition; 9% (95% CI 6.4-12.5), sion of different sports allows comparison of oral health status for
reduced training volume; 3.8% (95% CI 2.2-6.4), performance affected; the first time. It is reasonable therefore to generalize the findings to
5.8% (95% CI 3.7-7.9) and experienced oral pain; 29.9% (95% CI 25.3- elite and professional sport in the United Kingdom. We noted a dif-
25.0). The odds of an oral impact on sport performance were reduced by ference in prevalence of oral disease between sports and further
41.0% in men compared to women (OR = 0.6; 95% CI 0.4-1.0; P = .030). A analysis of self-reported oral health and risk behaviours may provide
severity score out of 100 can be calculated for these problems, and 31% of an insight into the reasons for this difference. The risk of systematic
athletesreported a nonzeroscore; the highest score reported was 94. bias was mitigated by training and calibration of the examiner
Each variable was dichotomized to effect/no effect (Tables S11, against a gold standard. However, repeat examination of a sample of
S12). The presence of dental caries was associated with nonzero score athletes during the screening visits to assess ongoing repeatability
for difficulty eating (P = .048). The presence of any PUFA lesion was was not possible due to athlete time constraints. No radiographs
also associated with nonzero scores for difficulty eating (P = .027), were taken in this study, and therefore, the estimates of oral disease
relaxing (P < .001) difficulty participating in normal training or compe- may under-report actual prevalence.
tition (P = .002), experience of oral pain (P = .001) and “any sport per- These data are consistent with data from previous research7-9
formance impact” (P = .005). There were associations with oral health (Figure S15). We did not recruit a control population to the study, but a
status and psychosocial impacts including pain (Table 1). For general cautious comparison with a similar age group from the most recent
health status, there were associations between relaxing (including national oral health survey in England and Wales (ADHS 2009) can be
sleeping) and all sport performance impacts. Several self-reported oral made.15 We reported established caries in 49% of athletes compared to
health problems (Table 2) had an association with athlete-reported 36% of adults aged 25-34 from the ADHS 2009; 15% of athletes had 3
impacts on well-being or sport performance (Tables S13,S14): current or more teeth affected compared to 10% of a comparable group from
pain or problem related to teeth (P < .001), sensitivity to hot or cold the ADHS 2009. We found that 22% of athletes had pocket probing
(P = .006), bleeding when cleaning teeth (P = .04) and history of swel- depths of ≥4 mm compared to 19% of adults aged 16-24 from the
ling or infection around wisdom teeth (P = .001). ADHS 2009. We reported ETW in 42% of athletes with a BEWE score
9 or more in 12%; the ADHS 2009 reported toothwear in 52% of adults
aged 16-24 with moderate wear in 4%; the prevalence of ETW was
4 | DISCUSSION greater in men than women in both groups. Performance impacts (non-
zero) reported in the ADHS 2009 such as impact on eating (20%),
This study provides strong evidence of the prevalence of oral health impact on relaxing (12%), impact on smiling (15%) and impact on work
diseases and associated performance impacts in elite athletes; estab- (4%) are generally lower than those reported by the athletes in this sur-
lished caries was present in 49.1% of athletes and ETW present in vey who may have higher expectations of physical function, psychologi-
42.0%. Excellent periodontal health was rare; more than three quar- cal function and perceived health.19 It is important to recognize that the
ters (77.0%) of athletes had gingival bleeding on probing/calculus ADHS 2009 includes greater representation of disadvantaged popula-
present, and we measured a pocket probing depth of 4 mm or more tions who are known to have higher levels of oral disease. Therefore,
in a further 21.0%. We judged the samples to be representative of the sporting environment may negatively influence oral health in elite
each team (other than athletics) with each at least 75% participation athletes within this sample. Furthermore, the lifetime burden of treat-
in the study. The odds of having caries in mixed/team sport were ment need and effect on quality of life on athletes should be consid-
2.4 (95% CI 1.5-3.8) times greater than in endurance athletes ered.20 Severe events such as acute dental or orofacial infections can
(38.5%) and odds of erosion 2.0 (95% CI 1.3-3.1) times greater in lead to time lost from training and even competition; however, they
team/mixed sport than endurance sport. Caries prevalence was not occur infrequently. Chronic impacts which may not lead to time loss,
associated with age, gender, ethnicity or educational status; how- but rather a reduction in quality of training, are commonly reported, and
ever, ETW was more prevalent in male athletes. at elite level may have important consequences.21
GALLAGHER ET AL. | 5
T A B L E 1 Associations between clinical indicators of oral health, general and oral health status, and athlete-reported performance impacts
(nonzero score)
Number (%) with the condition Number (%) with the
and at least one impact condition and at least one
on daily activity Odds ratio (95% CI) P value impact on sport performance Odds ratio (95% CI) P value
All (n = 344) 169 (49.1%) 110 (32%)
Number of decayed teeth
None 78/175 (44.1%) 1 55/177 (31.1%) 1
One or more 91/169 (54.5%) 1.52 (0.99-2.33) .050 55 (32.9%) 1.089 (0.692-1.714) .711
Any PUFA
No 160/332 (48.2%) 1 101/332 (30.4%) 1
Yes 9/12 (75.0%) 3.23 (0.86-12.12) .080 9/12 (75%) 6.861 (1.819-25.876) .005
Periodontal condition
BPE 0, 1 or 2 80/268 (29.9%) 1 80/268 (29.9%) 1
BPE 3 or 4 30/76 (39.5%) 1.53 (0.90-2.60) .110 30/76 (39.5%) 1.533 (0.903-2.602) .114
Erosion
BEWE score < 6 68/198 (34.4%) 1 65/198 (32.8%) 1
BEWE score ≥ 7 51/146 (34.9%) 0.97 (0.62-1.53) .910 45/146 (38.8%) 0.912 (0.576-1.444) .693
Self-reported general health
Very/good 145/310 (46.8%) 1 93/310 (30.0%) 1
Fair- very poor 24/34 (70.6%) 2.731 (1.264-5.903) .011 17/34 (50%) 2.333 (1.142-4.769) .020
Self-reported oral health
Very/good 97/238 (40.8%) 1 68/238 (28.6%) 1
Fair-very poor 72/106 (67.9%) 3.078 (1.899-4.989) <.001 42/106 (39.6%) 1.641 (1.015-2.652) .043
T A B L E 2 Associations between self-reported oral health problems and athlete-reported performance impacts (nonzero score)
Number (%) with the
Number (%) with the condition and at least
condition and at least one one impact on sport
impact on daily activity Odds ratio (95% CI) P value performance Odds ratio (95% CI) P value
Current pain/problem
No 146/317 (46.1%) 1 89/317 (28.1%) 1
Yes 23/27 (85.2%) 6.735 (2.277-19.921) <.001 21/27 (77.8%) 8.966 (3.503-22.949) <.001
Sensitivity to hot or cold
No 113/253 (44.7%) 1 72/253 (28.5%) 1
Yes or occasionally 56/91 (61.5%) 1.982 (1.215-3.235) .006 38/91 (41.8%) 1.802 (1.095-2.966) .021
Bleeding when cleaning teeth
No 74/176 (42%) 1 48/176 (27.3%) 1
Yes or occasionally 61/112 (54.5%) 1.649 (1.023-2.657) .040 38/112 (33.9%) 1.369 (0.820-2.287) .230
History of wisdom tooth swelling/infection*
No 106/262 (40.5%) 1 70/262 (26.7%) 1
Yes 63/82 (76.8%) 6.735 (2.277-19.921) .001 40/82 (48.8%) 2.612 (1.565-4.360) .001